The Sequoia offers a weekly day programme for those with long standing and disabling emotional difficulties, mainly with a diagnosis of Borderline Personality Disorder but not exclusively. Community members are expected to attend from 10 am to 3 pm (5 hours per day) for 4 days per week (Monday, Tuesday, Thursday & Friday). Maintaining attendance is an important part of the programme with TC members committing to 80% attendance and making sure they ring in if they are not able to come. This is because of the way in which the Community functions, it is important that individuals can rely on other Community members. Remarkably, the attendance threshold was originally set at 60% attendance and this was voted on by members of the TC to be raised to 80%, showing just how committed the service users really are to this programme. Each service user is entitled to ‘holidays’ (13 days + bank holidays) to ensure equality/diversity. Members manage their own diaries and their own leave.
Co-Production
From start: Yes
During process: Yes
In evaluation: Yes
Evaluation
Peer: Yes
Academic: Yes
PP Collaborative: Yes
Find out more
Suzanne Brown - Clinical Lead NAViGO Health and Social Care CIC
THE PROBLEM:
In July 1996, major changes were proposed to the Mental Health Act (1983) following the Lin and Megan Russell case who were beaten to death during a robbery by Michael Stones, who was diagnosed with a Personality Disorder (PD). These reforms brought a new focus to Personality Disorders and how people should be detained.
The Mental Health Act 2007 enacted changes to the way in which people were detained under the Act. Locally, this was also when Dr Wojciech Gierynski (who has a special interest in PD) and Suzanne Brown (NAViGO) Clinical Lead) wanting to work with this group of services users formulated a group of staff and trained in delivering Dialectical Behavioural Therapy (DBT). This team at the time was called the Personality Partnership. Over time delivering DBT alongside our already full time posts posed some inconsistency in the service that was offered.
What became apparent to them was that individuals with a Personality Disorder diagnosis were getting stuck in the system, often with extremely long inpatient stays, which actually conversely often has a detrimental effect on people with this type of illness. In fact, this key Group of service users (6 people) were found to account for most ‘revolving door’ admissions within NAViGO with subsequent high bed day ratings (1045 days from April 16-April 17 equating to £418k).
Suzanne and Wojciech visited a number of different settings around the country to understand what was currently available for people with PD. Following a visit to the Cawley Centre in London the whole concept and principles of the therapeutic community way of working appeared to be an innovative way to work with such complexities. Curiosity and an eagerness to learn about the model the whole ‘new team’ enrolled on the ‘Living Learning Experience’ to experience how a TC functions in reality.
Feeling energised and excited about a new way or working it was at this point that NAViGO signed up to The Community of Communities, a Royal College of Psychiatry scheme that provides core standards for TCs. The C of C operates in a similar way to the AIMS programme, in that it undertakes peer reviews of services to encourage best practice.
The Sequoia Therapeutic Community opened at NAViGO’s Harrison House site in September 2015.
THE SOLUTION:
The Sequoia offers a weekly day programme for those with long standing and disabling emotional difficulties, mainly with a diagnosis of Borderline Personality Disorder but not exclusively. Community members are expected to attend from 10 am to 3 pm (5 hours per day) for 4 days per week (Monday, Tuesday, Thursday & Friday).
Maintaining attendance is an important part of the programme with TC members committing to 80% attendance and making sure they ring in if they are not able to come. This is because of the way in which the Community functions, it is important that individuals can rely on other Community members. Remarkably, the attendance threshold was originally set at 60% attendance and this was voted on by members of the TC to be raised to 80%, showing just how committed the service users really are to this programme. Each service user is entitled to ‘holidays’ (13 days + bank holidays) to ensure equality/diversity. Members manage their own diaries and their own leave.
The model used for The Sequoia is based on the work undertaken by William Tuke (who founded The Retreat in York (http://www.rcpsych.ac.uk/pdf/online%20archive%201%20william%20tuke.pdf). Tuke philosophised people needed to be given meaningful support and valued roles/jobs in order to be released from the asylums of the time. The Sequoia offers an intensive 24 month psychotherapy programme where learning can come from understanding one another, and supporting each other in the process of change and mutual recovery. Therapy comes from whole-hearted participation in the whole programme. Sequoia plans to offer a 24 months “leaver’s programme” after this first Group reaches the end of the two year period.
a) THE TEAM:
A small but dedicated team of five staff oversee the Community currently two Social Workers, one of which is also the Clinical Lead; 1 Senior Nurse Practitioners, a part time psychologist, a Health Care Worker and a Consultant Psychiatrist.
b) REFERRAL PROCESS:
We have made the referral process simple as we don’t want paper work and forms filling to block entries into our programme. To make a referral, colleagues need to email both Suzanne Brown and Wojciech Gierynski with brief details about the individual, this must include their name and Silverlink number (NAViGO’s electronic patient record system) and why the referrer thinks the individual needs the TC. There are no forms to fill out as the team will then look into the case history and invite the service user in for a discussion saving additional stress around form filling.
Community members can be anyone who has a complex history, is emotionally unstable and chaotic in presentation. It may be that other services are struggling to manage these individuals.
The TC acts as Care Coordinator for its members to offer consistent approach – PD service users tend to be chaotic across all services so this model reduces strain on colleagues and improves the experience for service users.
To minimise ‘drop out’, all potential new service users go through a starter process which includes 10 x 2 hour sessions, consisting of Mentalisation Based Therapy and meeting the Group. Sessions include staff and 2 service users so that when a new service user commits fully there is a degree of familiarity. This is also an opportunity to explain rules, standards and give the new service user the opportunity to understand how the programme works.
There is an exclusion criteria for substances misuse but people are directed into dual diagnosis services and then supported to revisit Sequoia once this is no longer an issue.
c) HOW DOES SEQUOIA WORK?
Service users live together as a Community including cooking, eating together whilst supporting each other to face their own personal challenges.
There are a range of therapies employed by the Community which include:
• Mentalisation Based Therapy (MBT)
• Dialectical Behaviour Therapy (DBT)
• Laughter Yoga
• Cognitive Analytical Therapy (CAT)
• Group Therapy
• Art group
The Sequoia strives to work towards the Core Values identified by the Community of Communities (regulatory body) – these common shared values which underline all aspects of the work are:-
• Promoting developing healthy attachment
• Offering safe and supportive environment for containment of emotional distress
• Respecting and valuing everyone’s individuality
• Developing communication skills to learn to understand each other
• Establishing supportive relationships with others
• Encouraging full participation to influence one’s environment
• Finding a balance in accepting that positive and negative experiences are necessary for healthy development of individuals
• Taking responsibility for self and the Group
The main goals of treatment for each Community member:-
• To be able to regulate emotions through the discovery of alternative skillful behaviours
• To be able to form and sustain meaningful relationships
• To be able to manage dissaociative symptoms, if present.
• To have gained confidence and to be able to find purpose in life determined by themselves
• To have gained awareness of their own identity.
• To be able to live more independently than prior to commencement of the Sequoia with less reliance on mental health services.
Democracy is the concept that underpins everything at The Sequoia; the team strive to create a family atmosphere so that each individual who is part of the Community takes responsibility for their own actions, gets involved and helps to make decisions as a collective Group. It is about respecting each other and in turn giving each person a voice. This helps to build confidence based on the attachment theory. Everyone has a view, and is encouraged to make decisions on, for example, menus/cooking, cleaning, rules and even voting people in or out of programme.
Healthy attachment is a developmental requirement for everyone and should be seen as a basic human right. The ability to form relationships with others is formed when we are children and unfortunately it is extremely common for people with a PD diagnosis to be victims of abuse when younger or to lack the relevant role models to learn how to develop relationships properly.
Due to the complexity, it is prerequisite that individuals referred to Sequoia TC are on the Care Programme Approach (CPA). There is input onto the Acute Inpatient Units with MDT meetings where appropriate.
Family support meetings occur weekly to educate, enable and extend family networks around supporting TC members in the home environment and beyond the length of the programme.
d) THE ETHOS:
Therapeutic Communities (TCs) are structured, psychologically informed environments. They are places where the social relationships, structure of the day and different activities are all deliberately designed to help people’s health and well-being.
In TCs people with various longstanding emotional problems spend time and engage in therapy together in an organised and structured way, without drugs or self-damaging behaviour, so that a new life in outside society is made possible.
The clue is in the title. TCs function as communities, with all members expected to commit to their values and standards. This is a key element of the programme in that people must accept responsibility for their own actions and behaviours in order to be allowed to join the Group. In a nutshell, it is designed to mimic a family environment where certain expectations are placed on Community members in order to build their social relationships and improve their overall health and well being.
The Sequoia operates very much along these lines with TC members ‘gelling’ and living with family values but expected to have transparency; being challenging i.e., ‘what do you do in a disagreement’; making positive relationships/attachments and beginning to learn how to control emotions to decrease self-harming/self-defeating behaviours.
e) A DAY IN THE LIFE OF…
The programmes/structure within the TC are decided upon by the Group in a totally democratic way, a typical weekly example of this would be:-
Monday
‘Check In’
• Business Meeting
• Large Group (informal)
• Lunch
• Structured Programme without deviations unless agreed
Tuesday
‘Check In’
Cookery
• Large Group (informal)
• Lunch
• Structured Programme without deviations unless agreed
Thursday
‘Check In’
• Devise menu for Healthy Eating on Friday
• Prep work for Friday menu
• Lunch
• Art Therapy
Friday
‘Check In’
• Keep Fit Friday
• Large Group (informal)
• Healthy Eating Lunch
• Structured Programme without deviations unless agreed
‘Check In’, which is the first thing to occur every morning, involves each person in the Group speaking about their feelings in advance of the session. The service user speaking holds on to a NAViGO brain (promotional stress reliever) which encourages the rest of the Group to listen carefully during that time.
Weekly Business meetings are Chaired and Minuted by Service Users. Members manage their own rules and revisit boundaries on a monthly basis.
Wider Active Support
The sheer nature of the service itself and the privacy afforded to service users, makes it difficult for NAViGO to have active partners actually within The Sequoia per se. However, we work very closely with the Royal College of Psychiatrists and the Community of Communities to always ensure our service is second to none and fully aligned with best practice.
Other ‘partners’/stakeholders who help us to drive the service forward/maintain the equilibrium for service users are:-
o AIMS
o Acute Adult (internal partner)
o Community Services
o Children’s services
o PIP (Benefits Agency)
o Care- Coordinators
Co-Production
The whole service revolves around inclusivity and is managed using democracy trying to ensure inclusion and empowerment. For example:-
• The members decided on a ‘Warning’ system – e.g. if a member’s attendance drops below 80% then they receive a ‘Warning’; if they partake in alcohol or substances they receive a ‘Warning’; challenging behaviour in the Group (or externally) has the same result. Once a TC member reaches 3 Warnings, the rest of the Group call a meeting (which includes the person involved) and enquire if the programme is working for them, making suggestions on how they might change behaviours/manage conflict.
• If anyone from the TC presents in Crisis Service the night before a session then this is always discussed in Group the following day to manage and promote responsibility and empowerment.
• The Group excludes anti-social behaviour and people doing it are confronted by the rest of the Community.
• The Group choose and prepare their own menus; sharing and eating this in a family atmosphere
• The attendance policy was 60% but over time it has been increased to 80% and is set by the Community members themselves.
• The Community sets its own boundaries and rules; collectively ensuring adherence.
Looking Back/Challenges Faced
1) People with PD tend to use self-defeating behaviours to dull the distress caused by powerful feelings or impulses, commonly reporting a range of related difficulties, making treatment challenging:
• Sudden and extreme swings in mood and feeling states
• Impulsiveness – act without thinking
• Frequent feelings of emptiness and boredom
• Difficulty with a sense of self – who you are, what are you like
• Difficulty with relationships, with a pattern of intense attachments to people which keep breaking down
• Occasional episodes of loss of contact with reality or other experiences which might be seen as psychotic
• Lack of confidence and self-esteem which shows through in difficulties managing your day-to-day life.
We reduced the possibility of ‘splitting’ between staff and the members by undertaking the role of care coordinator within our service. This ensures complete consistency of the expectations of services and the service that is given to the members.
2) When the TC was first set up it did not have a full and detailed business case attached to it prior to implementation. Initially this put a drain on the Adult Acute budget in funding the new service. However, the successful outcomes have meant the ROI realised from keeping people out of crisis services/bringing back from out of area placements has more than covered the original outlay (see Sustainability Section below).
3) It was difficult in the first year of service for Senior Management (SMT) to fully appreciate the impact due to the ‘closed shop’ nature of the Community. Whilst the privacy aspect of Sequoia is what empowers the service users to trust and support each other, the ‘double edged sword’ is that whilst the ethos protects service users, SMT viewed the TC as a ‘secret service’. This could not have been done any differently if the service was to operate as it should but the recent excellent Peer Review from RCP swiftly allayed any fears as to whether the idea was a good one or not.
Sustainability
Whilst the TC ‘Sequoia’ is not a new concept originating in the mid to late forties when the British Army used this model to treat their soldiers after PTSD front line fighting. NAViGO believe it is A GOLD STANDARD SERVICE. Other mental health organisations have closed their TC’s due to cuts in funding swallowing up running costs. This is where NAViGO ‘stands apart from the crowd’; being a social enterprise we can preserve our additional services by working smarter to preserve funds and ensuring sustainability.
In terms of key staff leaving post, NAViGO has an internal development model which cross-cuts our Acute Service, with employees being given the opportunity to train around working within the TC ensuring an ever present full staff contingent.
The Sequoia is very closely monitored by our Performance Team to ensure the cost of operation is covered (and surpassed) by the savings made in keeping service users well. A screen shot taken from NAViGO’s Data Warehouse Dashboard (unable to upload but available on request) shows that in the first year the service has prevented 5 admissions and reduced bed days associated with this Group by 546; a saving of £218.4k on the previous year.
Evaluation (Peer or Academic)
As part of the Community of Communities initiative, Sequoia received a Peer Review on 20th September 2016. This works on the same principle as AIMS reviews undertaken for Acute Inpatient services in that Sequoia has been assessed against a set of core values by other mental health professionals. Results of this review are outstanding with the Royal College of Psychiatrists saying they were ‘blown away’ and advising The Sequoia to apply for accreditation after only one year of operation as it already currently meets all type 1 standards and a good percentage of type 2 standards.
The full report can be seen upon request.
Outcomes
The outcomes we have seen from implementing this service have been wide spread with positive changes being seen in:-
• Service user outcomes/experience
• Patient safety
• Staff morale/less burn out
• Cost savings
• Reduction in out of area placements
Some good examples are:-
• The Friends and Family Score for Sequoia is 93.7%
• 50% of service users open to Sequoia have an improved outcome measured on the PROM
• 82.4% of service users open to Sequoia rated their care as excellent or very good (the remainder rated care as fair)
• Staff sickness rates have reduced not only within Sequoia but also within Acute Adult Inpatient units due a more relaxed environment helping with work related stress
• No complaints have been made about Sequoia and no incidents have occurred since opening
• The TC has recently brought back a service user who was in an out of area placement costing £500k per annum. She is now an active member of the Group and her programme of rehabilitation is being led by Suzanne Brown and care-coordinated by the TC
• Monthly audits on attendance show 80% which is remarkable for people with such complex needs
Since inception the TC Group has doubled in size. Originally starting with 9 service users, there are now 16 currently. There have only been 2 full drop outs with a further 3 people dropping out only to return shortly afterwards. Two people are also within the starter process which will increase the Group to 18 once completed (the maximum is 20).
The service user comments and case study below demonstrate the excellent outcomes/impact the service has had on service users lives:-
“Cannot thank the team enough, not only did they support me but my family were able to access support and guidance for themselves to help understand my needs”
“Since joining the TC I have met other people who have BPD which helps me feel that I’m not so alone. The TC helps me learn new ways of thinking and take control of our emotions. Cannot thank the team enough, not only did they support me but my family were able to access support and guidance for themselves to help understand my needs.”
“You are the best thing since sliced bread.”
“Since coming to therapeutic Community, I feel I’m able to cope with family situations. I’m looking forward to the future.”
“I have seen big changes in myself and in others and I am now slowly being able to share some of my problems.”
CASE STUDY
Jane* is a current active member of the TC. Jane has been a prolific user of NAViGO services over the last decade and is an extremely hard case to manage as she refuses to engage with mainstream services to the extent that she has never had a care co-ordinator.
Jane has made numerous attempts at taking her own life (46 instances of self-harm and suicidal attempts recorded in the notes between 2007 and 2015). She also had 7 admissions over 9 years prior to joining Sequoia TC and her last stay within the acute lodges led to a seven month admission.
Last month Jane’s attendance at the TC was 100%. She attended all sessions and has shown remarkable progress since joining the TC.
*(Name has been changed to protect service user anonymity)
Sharing
Internally:
Morale has improved within the whole Acute staff Group. Being part of The Sequoia is a 2 way learning process; working with 16 complex individuals in one area at one time is a big learning curve. However, removing often chaotic PD service users from the main general in-patient units has brought about a much calmer environment, aiding faster recovery for others and in tandem giving the PD patients the bespoke care/support needed. Staff working within The Sequoia share their knowledge and experience with colleagues when working on the wards.
With the permission of the TC, a Laughter Yoga demonstration was given at the 2016 AGM and service users took part in two open days which included baking and raffles.
Externally:
With the permission of the Group, we have had many visitors to The Sequoia including:-
• The Royal College of Psychiatrists
• The Positive Practice Team
• The Care Quality Commission
• The Community of Communities
Our commitment to sharing our practice is evidenced by the number of national awards NAViGO has won. Whilst we are always delighted to be recognised, our main driver for applying for award nominations is to ensure a service we know works is disseminated to other health organisations.
Is there any other information you would like to add?
